Intended for healthcare professionals

Clinical Review State of the Art Review

Anticoagulation in atrial fibrillation

BMJ 2014; 348 doi: (Published 14 April 2014) Cite this as: BMJ 2014;348:g2116
  1. Benjamin A Steinberg, postdoctoral fellow12,
  2. Jonathan P Piccini, assistant professor of medicine12
  1. 1Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA
  2. 2Duke Clinical Research Institute, Durham, NC, USA
  1. Correspondence to: B A Steinberg benjamin.steinberg{at}


Atrial fibrillation increases the risk of stroke, which is a leading cause of death and disability worldwide. The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke, estimated by established criteria, improves outcomes. However, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential. Vitamin K antagonism has been the mainstay of treatment; however, newer drugs with novel mechanisms are also available. These novel oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) obviate many of warfarin’s shortcomings, and they have demonstrated safety and efficacy in large randomized trials of patients with non-valvular atrial fibrillation. However, the management of patients taking warfarin or novel agents remains a clinical challenge. There are several important considerations when selecting anticoagulant therapy for patients with atrial fibrillation. This review will discuss the rationale for anticoagulation in patients with atrial fibrillation; risk stratification for treatment; available agents; the appropriate implementation of these agents; and additional, specific clinical considerations for treatment.


  • Contributors: BAS performed the literature searches and compiled source documents. BAS and JPP jointly interpreted the data and drafted and revised the manuscript. Both authors approve the final version of the manuscript and are guarantors. The authors certify that the manuscript represents their own work and are solely responsible for its content.

  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: JPP discloses institutional research grant support from Janssen Scientific, GE Healthcare, ARCA pharmaceuticals, and ResMed; and consulting relationships with Johnson & Johnson, Pfizer/BMS, Medtronic, and Spectranetics. BAS was funded by NIH T-32 training grant #5 T32 HL 7101-38.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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